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Call One Reporting Sheet
Home
Call One Reporting Sheet
Navigator Name
First
Last
Client Name
First
Last
Client Enrollment Date
MM slash DD slash YYYY
Client Phone
Have they received your insurance card?
Yes
No
Do any of the following apply their situation?
Did not receive payment information from the insurance company
I moved or changed my address
I received payment information but have not paid the premium
N/A
Have they made an appointment to see a doctor since they enrolled in coverage?
No
Yes
N/A
Do they plan to go to a doctor or health care provider in the next 6 months?
Yes
No
N/A
Why don’t they have plans to go to a doctor or health care provider?
Cannot afford the copayments or the deductible when I go to the doctor
Cannot find a health care provider
I’m pretty healthy and don’t feel like I need to see a provider
N/A
(Select all that apply)
Would they like assistance with one of the following services?
Getting to know my insurance plan and how to find an “in network” provider
Getting to know my insurance plan and understanding which services are free preventive services
Understanding what to do if my income changes or if I move to another address
N/A
Did they schedule an Appointment post call?
Scheduled
Did Not Schedule
Did they schedule an Appointment post call?
Scheduled
Did Not Schedule
Did you provide Education?
Yes
No
Anything else to add about the call?
Δ